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'1 'lAdMIETNV1 0AN"L VA* -UF-MS-ffl%Y%C8ffD A "*"1%0A" <br /> pp IPLERS <br /> ' (See fieders$ 4or Instructions) NO <br /> PROJECT NAME C _ SAMPLE CONTAINER SAMPLE DESCRIPTION CODES TAT CODES <br /> DESCRIPTION CODES A Ground Water F Oil <br /> PROJECT NUMBER A 40-ml VOA Vial a Surlaco Water G Waste landard <br /> (SIGN) a Glass Luer E Brass Tune C Leachate H Blank/Spike r <br /> C Plastic SW ml F Other � D Rinaeat 1 %her� 3 24 Hour <br /> RECORDER (SIGN) D Plaslk Liter E SailSe�ment �,a�]n 4 81ner_ <br /> NUMBER OF ANALYSIS REQUESTED ��JLABORATORY USE ONLY_ <br /> CONTAINERS <br /> AND <br /> PRESERVATION $ _ <br /> S SAMPLE <br /> NOTES ASSIGNED <br /> BOTTLE UPON <br /> CONDITION <br /> DATE I TIME SAMPLE ID NUMBERS RECEIPT NOTES <br /> { 1 <br /> _ C <br /> i <br /> t I <br /> NOTES I MISCELLANEOUS nq I e by { gnature) Received By (Sig lure Date Time <br /> L,2' <br /> i <br /> "�Aelinq s ed By signature) Redbived B4 <br /> ature) Date Time <br /> Relinquished By (Signature) Received By (Signature) Date Time <br /> 1 Method of Shipment Description of Other Chains4X-Custody Dispatched By (Signature) Date Time Received for lab By (Signature) Date Time <br /> Transport Containeris <br /> sin by S vial Serial ) <br /> Send Lab Results to (Name) (Check Office Below) Verbals Requested Yes No E] <br /> IPORTER EA PLEliSANTON ❑ IRVINE ❑ ATLANTA ❑ OTHER _ <br /> TEL(219)926-8651 TEL(43k 463-9117 TEL(714)757-1755 n TEL(404)951-0055 TEL <br /> FAX(219)9287109 FAX(;)15?4632981 FAX(714)757-0960 FAX(404)951-9354 FAX <br /> ❑ DENVER + ❑ KIN@8F PRUSSIA ❑ HOUSMN ❑ MT VIEW ❑ OTHER <br /> TEL(303)79x1747 TEL(215)337-2551 TEL(713)556.1666 TEL(415)960.1640 TEL _ <br /> FAX(303)789-0188 FAX(215)337-0560 FAX(713) 6580666 FAX (415)960.0739 FAX <br /> CANONIE ENVIRONMENTAL SERVICES CORP a 800 CANONIE DRIVE o PORTER, IN 46304 • TELEPHONE 219 926-8651 a FAX 219 926-7169 <br /> SERIAL NQ 09619 WHITE Fbid Copy YELLOW Project Copy PINK Laboratory Catty <br />